India’s only exit strategy is to urgently bring covid-19 infection rate down and to vaccinate as much of its population as quickly as possible, says Ami Banerjee
We all want to be different which makes us all the same. Around the world, country after country has been caught out by this line of thinking whether Italy, the UK, the USA, Brazil, or currently, India. The flames rising high in my great country of origin remind me of the first covid-19 wave in the UK. I hear of the horror from my friends, family, and colleagues around India. We are dealing with a pandemic that can infect, affect, and dissect all of us, wherever we are.
We have known for at least 14 months that the main determinants of excess mortality due to covid-19 are baseline risk of mortality, the relative impact of the pandemic, and the population infection rate. The first two are not modifiable in the short-term. Only reducing the infection rate with a full suppression strategy via stringent lockdown will act quickly within days to reduce the daily death toll. Yet the majority of funding, resource and policy planning, research, media coverage, and public attention continues to focus on the first two issues rather than the third, regardless of country.
Beyond making sure that people at high risk are taking their medications for pre-existing conditions and shielding until they are vaccinated, baseline risk takes time to reduce. The profound strain on treatment and prevention of non-covid related diseases, in health systems hit hard by the pandemic, will probably lead to more indirect deaths over the coming year. However, in the acute throes of covid-19, the only way to protect services for other conditions in the context of massive resource shortages, is to reduce infection rate at scale.
Relative risk of the pandemic is not just due to the inherent infectivity and characteristics of SARS-CoV-2. For example, preliminary data suggest that concern about a so-called “Indian double mutant” virus is misplaced and it can be controlled by existing vaccines. The relative risk is not just acute mortality risk in intensive care units (ITU). The clamour to increase capacity for ventilators, ITU beds, and novel drug therapies will not stop the deaths quickly. You cannot “ITU your way” out of the pandemic. Most infected people do not reach hospital and most in hospital do not reach ITU; even more so in India at present, given the enormous strain on healthcare services. Field hospitals and emergency ITUs are a stop gap measure at best, but do not solve the problem. That is before we talk about the medium- and longer-term consequences in the form of long covid. A more pertinent and pressing factor in the relative risk is the resilience of a health system and the strain upon it. Even countries with established health and public health infrastructures such as the NHS have been brought to their knees over the past year. Although India has recently established policies of universal health coverage through Ayushman Bharat, the healthcare available to most of its 1.3 billion citizens is precarious, and so the relative impact of the pandemic is greater in this situation. Again, funding and developing robust, equitable, and sustainable universal health coverage are not feasible immediately and represent long-term policies.
Therefore, India’s only exit strategy, like all countries, is to urgently bring infection rate down and to vaccinate as much of its population as possible as quickly as possible, starting with the most vulnerable where the numbers needed to treat are least. SARS-CoV-2 does not respect mass gatherings whether social, religious, or political. It has not respected borders. It certainly does not respect high technology healthcare or high resource settings, instead respecting simple public health measures such as test and trace systems. On 17 March 2020, 79 deaths had been reported in England due to covid-19 and we reported that over 70,000 deaths would occur over the next year if infection rate was not checked. Our models, among others, forced a nationwide lockdown in the UK. Even then, increased infection rates over the following year surpassed our worst predictions, with over 120,000 covid deaths to-date. India, with a higher baseline risk of mortality and a higher relative impact of the pandemic, cannot afford to have a high infection rate without tens of thousands of avoidable deaths every day. The decision is an easy one, it just needs to be made. A nationwide lockdown and large vaccination drive are urgently needed. Many lives depend on it.
Amitava Banerjee, associate professor in Clinical Data Science and Honorary Consultant Cardiologist, Institute of Health Informatics, University College London.
Competing interests: none declared.